Divorce / Annulment Worksheet
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1
2DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Wis. Stat. ch. 69
Division of Public Health
F-05080 (Rev. 12/15)
Page 1 of 2
DIVORCE / ANNULMENT WORKSHEET
CANNOT BE USED AS PROOF OF DIVORCE
The maximum penalty for providing false information used to create a vital record is one thousand dollars ($1,000) or ninety (90) days in jail or both, per
Wis. Stats. § 69.24.
The Clerk of Court is responsible for filing an accurate and complete Divorce / Annulment Worksheet with the State Vital Records Office for every divorce or
annulment finalized in that court per Wis. Stats. §§ 69.08 and 69.17.
PARTY A
1. CURRENT NAME: First
Middle
Last
Suffix
2. BIRTH NAME: First
Middle
Last
Suffix
4. RESIDENCE – COUNTRY/STATE
5. RESIDENCE – COUNTY
3. DATE OF BIRTH (MM/DD/YYYY)
6. SOCIAL SECURITY NUMBER
PARTY B
7. CURRENT NAME: First
Middle
Last
Suffix
8. BIRTH NAME: First
Middle
Last
Suffix
10. RESIDENCE – COUNTRY/STATE
11. RESIDENCE – COUNTY
9. DATE OF BIRTH (MM/DD/YYYY)
12. SOCIAL SECURITY NUMBER
MARRIAGE INFORMATION
13. MARRIAGE – DATE (MM/DD/YYYY)
14. MARRIAGE – COUNTRY/STATE
DECREE INFORMATION
15. DATE OF DECREE (MM/DD/YYYY)
16. TYPE OF DECREE
17. COURT CASE NUMBER
18. COUNTY OF DECREE
Divorce
Annulment
I certify that this document reflects the facts concerning the dissolution of the marriage of the above named parties.
19. CLERK OF COURT/DEPUTY SIGNATURE
20. DATE SIGNED (MM/DD/YYYY)
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